mikie
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Morphine (except for P.O. Tylenol lol) is the only analgesic in the Maryland pharmacopeia.
Rsi
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Morphine (except for P.O. Tylenol lol) is the only analgesic in the Maryland pharmacopeia.
Fentanyl is optional as a premedication along with Lido and Benzocaine, and per the words of the protocols even Etomidate is optional.
"Versed 5mg IVP/IN
If not sedated sufficiently to intubate in 60 seconds: Etomidate 0.5 mg/kg IVP"
I remember when first looking these over being a bit surprised there was no paralytic. This is just one medical system of many in the metro area.
All the research I have done into Pharm texts, anesthesia and airway experts lists Versed as a drug that should not be used as an induction agent do to the fact that the dosing needed is so high and has so many negative side effects. Most suggest its use in the 2-5 mg range in the addition to Etomidate but not alone. I also found it interested that some agencies are still using Roc as a defasiculating agent as newer research has shown that it is not effective for that. Our goal is to provide the best care allowed by our protocols and remember we are not doctors just technicians.
Versed is a wonderful tool and does have it's place, however I do agree there are other options that may be more beneficial (i.e. Etomidate, Ketamine, etc.)
I don't know of too many progressive agencies that even consider a defasic'ng agent as many have completely moved away from Sux and use Roc (or Vec) exclusively as their NMBA.
Yes the goal is to provide the best care, fortunately many of us are not limited by protocols and are able to operate in an autonomous fashion under clinical guidelines. Focusing on allowances and emphasizing a technician level does nothing for the promotion of professional development.
Smash
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And 'versed' depending on the situation. But I love ketamine. Very much.
60 seconds doesn't seem like a long enough time to wait for midazolam to take effect. I think it's rare to have intubating conditions that quickly when using fentanyl + midazolam without a paralytic.
Personal opinion (for what little it's worth): a large proportion of the difficulty seen when using opiates + benzos for a facilitated intubation is providers failing to wait long enough for the medications to take effect prior to attempting laryngoscopy.
Unfortunately this seems to be fairly common in metropolitan regions. There seems to be an assumption by many physicians that a crew within a city can just run to the ER and have their patient intubated by an ER fellow within 60 seconds of entering the ambulance bay. 10 minutes of critical hypoxia is devastating whether it happens in the field, or in during transport / the ER bay / triage / initial assessment by the EP.
There's obviously a deficiency in paramedic education and ongoing training when it comes to intubation in some (many?) systems.
The opinion of many medical control groups seems to be that approaching airway control with benzo's + opiates is safer than doing RSI. Perhaps because the fentanyl can be reversed quickly, or because the incidence of apnea is lower than when using NMBAs. But I think sometimes (again, my very inexpert opinion), it just allows providers to make a bigger mess out of an already potentially difficult airway.
Damn it Smash you confuse the heck out of Brown, should I look for you on my next shift or not
We have midazolam for neurogenic cause for coma with GCS less than or equal to ten, everybody else gets ketamine
I agree pretty much on all counts. There are a lot of systems here and for curiosity's sake I'm going to look at others to see what they do. There are some places here that are slow to come around to change and being progressive, and I suspect that's the case in many (not all) big city/metropolitan areas. Phoenix is not one of them, that I know.
I work in WA and Versed is listed as an appropriate substitute for Etomidate. Our initial dose is 2-5mg and afterwards .05-.1mg/kg to continue sedation. We have some medics that use Versed exclusively because they dont want to do the math, but it is supposed to only be used if pt has an allergy to Etomidate.
Smash
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I have a fair bit of experience using versed (and fentanyl) for induction. Used appropriately it is a perfectly good drug most of the time. There are
times where there are better options (like ketamine). The key is to educate and empower (can you tell I've been watching Oprah?) the paramedics to use the most appropriate drug for the situation.
Personally I think that the 2-5mg for induction, even with fentanyl, is grossly underdosing the patient and is inhumane. If the powers that be are really worried about the negative cardiovascular effects they should consider better options like ketamine.
I've said it before and will no doubt say it a million times again: Drug assisted intubation needs to be done properly or not at all.
times where there are better options (like ketamine). The key is to educate and empower (can you tell I've been watching Oprah?) the paramedics to use the most appropriate drug for the situation.
Personally I think that the 2-5mg for induction, even with fentanyl, is grossly underdosing the patient and is inhumane. If the powers that be are really worried about the negative cardiovascular effects they should consider better options like ketamine.
I've said it before and will no doubt say it a million times again: Drug assisted intubation needs to be done properly or not at all.
It's my turn to testify! Sing it loud Brother Smash!
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If you are only using a benzo to facilitate intubation then I agree 2-5mg is nowhere near enough, but what about in conjunction with a paralytic? Before we started carrying etomidate we'd use either versed or fentanyl (or a combo) along with sux/vec/roc; it took a little more thought to do it appropriately, but could be done well, especially as it was always followed up with repeat dose at fairly short interverals.
Smash
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I don't think that a benzo alone or with fentanyl should be used to facilitate intubation. Unless you are doing a true "awake" intubation on a patient with ketamine or something, we need to make sure that airway reflexes are eliminated along with awareness to provide both the optimal intubating conditions and the optimal in humane patient care.
Even when using a NMBA 2-5mg as a blanket dose is suboptimal. It might be ok for a colonoscopy, but it's not ok in your head injured, fractured, trismused patient.
So my recipe using versed is: 0.1mg/kg of versed (and this is a light dose) to eliminate awareness. I may reduce this if perfusion is tenuous, but really, that is what ketamine is for. Fentanyl 5mcg/kg or thereabouts. I know that pre-medication is a bit up in the air, but my rationale is that intubation is a painful procedure, so it seems reasonable to me to add some pain relief for a start. It's also hopefully synergistic with the benzo and may help blunt the sympathetic surge associated with laryngoscopy.
I'm then unfortunately required to use sux for passing the tube. My preference would be for rocuronium, but this is not currently an option for me.
Once the tube placement is confirmed and secured, I get another BP straight away, and because I have used a light dose of sedation I will add some more versed and fentanyl immediately with the dose dependant on the BP. It's then time for long term paralysis if I am going to use it at all.
Ongoing sedation and pain-relief is then achieved with an infusion of morphine (or fentanyl) and versed, at around 0.1mg/kg/hour +/- depending on perfusion, clinical situation and level of sedation. Some situations call for heavy sedation, others are fine reasonably light on.
Ongoing sedation and, most importantly, pain relief are vital, and I don't like the peaks and troughs associated with bolus dosing. If propofol is used for ongoing sedation (which I don't necessarily think is optimal in the field, although in certain situations it has it's place) then it is important to remember to include some pain relief along with it, as props has no analgesic effect.
It is more and more clear with each day that Smash is not human, he is some sort of Robocop type super ambo who has scanned billions of studies and textbooks into his mainframe, it would appear to include one or two on anaesthesia too.
All our RSI patients get fentanyl 1mcg/kg; those with neurogenic cause for coma who have a GCS =< 10 receive 0.05mg/kg midazolam, whereas everybody else gets 1.5mg/kg ketamie.
If you are over 60, heart rate is >100 and ..... something else (Brown can't be arsed signing into Moodle to get the Clinical Procedures) you get half dose of fentanyl and midaz (if ketamine is not used)
All our RSI patients get fentanyl 1mcg/kg; those with neurogenic cause for coma who have a GCS =< 10 receive 0.05mg/kg midazolam, whereas everybody else gets 1.5mg/kg ketamie.
If you are over 60, heart rate is >100 and ..... something else (Brown can't be arsed signing into Moodle to get the Clinical Procedures) you get half dose of fentanyl and midaz (if ketamine is not used)
The rest I agree with, was curious about this though. How well are you managing sedation with versed and morphine at 0.1mg/kg/hr? Just based on my weight, that's only about 1.5mg of each every 10 minutes. I rarely use MS (fentanyl=much better most of the time) but that just doesn't seem like enough, even in combination, to keep someone down. Though you are using a larger induction dose than I am, so that helps I'm sure.
Smash
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I will bump it up if need be, or tone it down, it depends on the situation, and whether I have long term paralysis on board as well, but I have never had any issues with under-sedation. I watch carefully for any signs of under sedation, and I tend to err on the side of heavier sedation than lighter, especially given the amount of stimulus present in an ambulance as opposed to an ICU. 0.1mg/kg/hr offers a good starting point.
Melclin
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Has anyone heard Richard Dutton speak on intubating hypovolaemic trauma pts?
He reckons that it basically doesn't matter which induction agent you use. You just can't use much of it. They're using thiopentol or propofol I think, traditionally agents you'd steer clear of in haemorrhagic shock. I guess the theory if it doesn't matter which one you use when it comes to circulatory collapse, you may as well have the positive effects on ICP, but I don't know and I'd be interested to find out.
Anyone have any light to shed on this or any thoughts?
SMASH: Are you using propofol to maintain sedation in ventilated intracranial bleeds with hypertension?
He reckons that it basically doesn't matter which induction agent you use. You just can't use much of it. They're using thiopentol or propofol I think, traditionally agents you'd steer clear of in haemorrhagic shock. I guess the theory if it doesn't matter which one you use when it comes to circulatory collapse, you may as well have the positive effects on ICP, but I don't know and I'd be interested to find out.
Anyone have any light to shed on this or any thoughts?
SMASH: Are you using propofol to maintain sedation in ventilated intracranial bleeds with hypertension?
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usafmedic45
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Well....remember the docs in Maryland don't trust the EMS providers so tend to right asinine orders like that. I mean....who needs a secured airway when you're going by helicopter to Shock/Trauma, the world's best unaccredited "trauma center"?
Well....remember the docs in Maryland don't trust the EMS providers so tend to right asinine orders like that. I mean....who needs a secured airway when you're going by helicopter to Shock/Trauma, the world's best unaccredited "trauma center"?
Hush you, the lure of Shock/Trauma is all it needs, any evidence to the contrary of its awesomness that is based in science is pure witch doctory Brown tells you, get the pitch fork and gasoline!
/taking the piss